This is about the 13th reorganisation I’ve seen in my 3 decades as a GP. Up till now I’ve put it all down to the fact that politicians can’t resist “fiddling”, and if we called all managers administrators instead, they’d administer rather than think they too have to introduce change for change’s sake or to prop up their egos. This “reorganisation” is far more sinister however as the label “NHS” will not be in any way applicable afterwards.

This White Paper ( WP ) represents the Coalition Government’s proposals for legislation to privatise the NHS. It is the next logical step in the seamless acceleration of the policies of the last Government. Tony Blair was elected in 1997 on a platform of abolishing the NHS market , but a few years later reversed this without a mandate from the electorate. The present Secretary of State gave a pre-election pledge that there would be no more major reorganisations in the NHS. And why wasn’t the NHS a “hot topic” in the election campaign ? Because all three main parties are in agreement that commercialisation is the way forward . Those believing in the founding principles of the 1948 NHS were disenfranchised. Now the main aim of the WP Mr Lansley has introduced is to hand over the provision of NHS care to private companies. This policy is called “ patient choice” To enforce this change, commissioning in England is to be privatised.

GPs have no choice but to amalgamate into consortia (GPCC) which have the task of commissioning the bulk of the NHS care under the control of a National Commissioning Board ( NCB ).
The GPCCs and the NCB are open to be largely run by private interests. The appointed NCB would contain figures from large health corporations. GPCCs in some areas are at risk of being dominated by a clique which would turn to the private sector to do the commissioning for them. There is a real danger of damaging conflicts of interests when “GPs” are both service providers and service purchasers
The present commissioners, the Primary Care Trusts and Strategic Health Authorities are a publicly run bureaucracy and would get in the way so are to be abolished by 2013.
This plan to privatise commissioning is skilfully hidden by saying that GPs will be in control of 80% of the NHS commissioning budget, through GPCCs. But these GPCCs would take over the debts of the PCTs and then have to ration care on a massive scale as they would be held responsible for cutting the NHS budget by £20bn ( a fifth of the NHS budget )
The nominally responsible GPs would then be blamed for the withdrawal of care and treatments and for closing hospitals.

The publicly owned infrastructure of the NHS is continuing to be closed down, sold off and privatised as the cuts proceed and the private companies such as BUPA and the US company UnitedHealth move in ( e.g. PFI and LIFT buildings, privatisation of NHS procurement, IT contracts, privatisation of ambulance and pathology services, ISTCs etc.). The new commissioners are instructed to carry out “patient choice”, by ending the present position of
“ NHS as preferred provider” and changing to an “any willing provider” policy.
The new “market” of competing providers would be regulated by MONITOR, which would also introduce price competition by abolishing national tariffs, and deciding “ best practice” tariffs. The new commissioners are instructed to continue the “reconfiguration” of NHS care by driving down GP referrals of patients to hospital, and removing hospital care.

The aim is to “liberate” the NHS from the structures founded in 1948
* Publicly owned hospitals and infrastructure,
* Publicly provided service by staff on national terms and conditions and pensions
* National system of education and training
The three parts of the NHS are all to be privatised.
— Community care is to be outsourced by April 2011.
— Primary care is increasingly owned and run by private health companies employing APMS general practitioners.
— The hospitals are to be denationalised. They must all become Foundation Trust businesses and then convert to “ social enterprises”. The latter are the transition stage to fully-fledged private hospitals. Hospitals must make money or go bankrupt and fail and must not be ‘bailed out.’

The consequences for NHS staff are the loss of thousands of posts through cuts, and the forcible transfer of employment to private companies with removal of national terms and conditions and NHS pensions.

The consequence for patients is the rapid and drastic removal of care provided; fewer hospitals miles from home, and the withdrawal of all types of treatments and care.
The WP demands increased individual patient budgets, which together with provision by private companies, paves the way for charges and private insurance.
The vision of the future is one in which corporate interests will be given incentives to select patients, time-limit care, sell top-up insurance, and introduce charges for some elements of care no longer provided by the NHS. The Government will then want to see the development of practices competing against one another for members (patients), just like US health insurers. That’s a chilling prospect for the elderly, those with chronic illness and people with mental illness and long-term needs, who are often of no commercial interest to the corporate because of their high healthcare costs.
The WP proposals will inevitably lead to the end of the NHS as a publicly owned and provided system of healthcare funded by taxation, with the right of every citizen to have access to comprehensive, high quality healthcare, free at the point of need. “NHS” will be nothing more than a title. Just as the USA is waking up to the inefficient, unfair, corrupt and discriminatory health care system they have, we are being driven in that direction— for ideological reasons.
The danger is that without careful and informed debate one of the best-loved and most successful public institutions of the last 60 years will go down undefended.
Dr Paul J. Hobday MB BS FRCGP DRCOG DFFP DPM

I fully agree with Paul’s analysis.
These reforms are ideologically driven with the main aim of reducing the public sector workforce, reducing public sector pensions, removing national T+Cs, and transfering public money to the private corporate sector. This allows Government to keep taxation low and control inflation in order to suit the needs of the City of London, investors, and the International Bond markets. This is why all 3 political parties support the idea of marketisation and privatisation of our public servicies. This has happened all around the world because of the deregulation of the financial markets and the potentially grave consquences of “capital flight” i.e unless the domestic polices of Governments suit the needs of the financial sector, investors will flee to other countries. Nations have lost sovereignty to the demands of global financialisation. This is neoliberalism in action and this explains why Labour became “New Labour”. Blair famoulsy said in a speech in Chicago:
“Every day about $1 trillion moves across the foreign exchanges, most of it in London. Any government that thinks it can go it alone is wrong. If the markets don’t like your polices, they will punish you.’
Two Labour MPs, Jon Cruddas and Jon Tricket, summed up this up will in the ‘New Statesman’ in 2007: ‘After years in opposition and with the political and economic dominance of neoliberalism, New Labour essentially raised the white flag and inverted the principle of social democracy. Society was no longer to be master of the market, but its servant.’

I would add that the “Big Society” is also a key part of the neoliberal agenda. The aim is to reduce public expenditure by replacing public sector jobs with the voluntary sector. This is known as “Social Capital”. When FTs become Social Enterprises, all employees will belong to the biggest “Social Enterprise” sector in the world. New employees will not be protected by TUPE legislation and will not be entitled to NHS pensions and national T+Cs. SEs will set their own local T+Cs.

I congratulate Paul on his excellent piece. The sooner that the profession wakes up to this impending destruction of the NHS, the better

I cannot understand why England has to just allow this to happen. 99% of people, both lay and professional seem to be against it but apparently we just have to accept it from a government which lied and wheedled it’s way into office. Why cannot the BMA etc. etc. refuse to implement such a retrograde step?

Thank you Paul and Clive for your professional insights and clarifications. These WP proposals are nothing short of calamitous. Yes there are failings and inefficiencies that require urgent redress, but the wholesale dismantling of our NHS in the way Lansley porposes is as abhorent as his duplicity. Thanks to my two new hips (waiting period from initial consultation to delivery of both only 9 months) I am in a position to take to the streets to defend the greatest institution this country has – one that is free at the point of delivery and which must please be fought for tooth and nail if we are truly to be called a civilised society. Keep up your great work and thank you.